Primary Bladder Neck Obstruction in Women: Current Management Paradigm

To systematically evaluate and synthesize the existing literature on treatment outcomes for primary bladder neck obstruction (PBNO) in women, given the absence of prior systematic reviews focused on this population. Current treatment options for PBNO in women include nonsurgical alpha-adrenergic receptor blockers (AB), surgical bladder neck incision (BNI), and investigational use of onabotulinumtoxinA injections (BTX-BN). Success rates for AB and BNI are approximately 50% and 75%, respectively, while BTX-BN appears to have lower efficacy. The existing studies on PBNO treatment in women are characterized by significant heterogeneity and a lack of high-quality evidence. Standardization is needed across multiple domains, including the definition of PBNO in women, the recommended diagnostic workup, and the establishment of criteria for treatment success and failure. Investigation of risk factors for treatment failure is also needed to better inform patient counseling and management.

DIAGNOSING BLADDER OUTLET OBSTRUCTION IN WOMEN

Urodynamic Differences Between Dysfunctional Voiding and Primary Bladder Neck Obstruction in Women

Modified Transurethral Incision for Primary Bladder Neck Obstruction in Women: A Method to Improve Voiding Function Without Urinary Incontinence

Bladder Neck Incision for Female Bladder Neck Obstruction: Long-term Outcomes

Bladder outlet obstruction is an uncommon condition in women. Primary bladder neck obstruction is one of the functional causes of bladder outlet obstruction. We evaluated surgical treatment in our patients with primary bladder neck obstruction. We retrospectively evaluated the medical data of 47 female patients from the Department of Urology who underwent transurethral incision of the bladder neck from January 2000 to December 2012. All patients underwent transurethral bladder neck incision at the vesical neck and proximal urethra at the 5- and 7-o'clock positions. We compared symptoms and urodynamic parameters before and after the operation. Out of 47 female patients who underwent the operation, primary bladder neck obstruction was diagnosed in 42. The mean age was 44.3 ± 16.8 (range: 21-78) years. The postoperative maximal flow rates were significantly increased (20.6 ± 3.9 vs. 7.6 ± 3.2mL/s, P < 0.0001), and the postvoid residual urine was decreased (31.3 ± 7.8 vs. 132.1 ± 22.24mL, P = 0.0002) compared with preoperative findings. Improvement was evident in most patients (83.3 %). A repeat operation had to be performed in seven patients (16.7 %). Operative therapy failed in one patient (2.4 %). The diagnosis of primary bladder neck obstruction in women is based on typical symptoms, uroflowmetry and multichannel urodynamics, including electromyography. Videourodynamics is obligatory in doubtful cases. Transurethral bladder neck incision is an effective therapy for female patients with primary bladder neck obstruction, and if necessary, a second procedure can be safely performed.

Treatment of Primary Bladder Neck Obstruction in Women With Transurethral Resection of the Bladder Neck

To present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI). Retrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4-5 and/or 7-8 o'clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline. Median patient age was 56.5 years (range 40-80). All presented with urinary retention-four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0-4.0] mL/s to 15 [10-22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22-76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients. PBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

ObjectiveTo present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI).MethodsRetrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4–5 and/or 7–8 o’clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline.ResultsMedian patient age was 56.5 years (range 40–80). All presented with urinary retention–four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0–4.0] mL/s to 15 [10–22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22–76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients.ConclusionPBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

Primary bladder neck obstruction (BNO) occurs when the bladder neck fails to open during voiding, causing urinary symptoms despite no anatomic obstruction. The cause of BNO is unclear but may involve neurogenic dysregulation related to the sympathic nervous system such as upper motor neuron lesion or peripheral autonomic neuropathy (small fiber neuropathy (SFN)). Another etiology can incuded increased sympathetic tone secondary to anxiety or stress conditons. Botulinum toxin A (BoNT-A) to the bladder neck has been used in our practice to treat women with BNO who failed conventional therapies (alpha blockers, relaxation strategies). This is the first report of patient-reported outcomes after BoNT-A treatment in women with pelvic pain and BNO. We included female patients with pelvic pain and BNO who received BoNT-A to the bladder neck between January 2022 and March 2023, and mailed self-reported outcome questionnaires. The primary outcome was the Global Response Assessment (GRA); secondary outcomes included pain scores on the Visual Analogue Scale (VAS) and symptom checklists. BNO was diagnosed using Nitti Criteria (high bladder pressure, low flow in bladder neck on video urodynamics), supplemented by additional criteria (e.g., high voiding pressure, prolonged attempts, Valsalva effort, and cystoscopic evidence or symptoms related to BNO). Urodynamic studies followed International Continence Society standards. Additionally, due to BNO's association with SFN, patient history of biopsy-confirmed SFN was recorded. Our inclusion criteria was satisfied among 18 patietns, with 17 completing the questionnaire. Out of those, 14 patients (77%) reported improvement on the GRA, with an average VAS of 8.3 ("Very Helpful"). The most commonly improved symptoms were feeling of incomplete emptying, difficulty starting stream, urethral burning, pain with urination, and pelvic pain. Postoperative symptom flares were reported in six patients for an average of 16 days. All six patients with biopsy-confirmed SFN showed significant improvement (VAS 8.7). Total of 14 patients (77%) indicated they would repeat the procedure. BoNT-A to the bladder neck significantly improved pelvic pain and refractory hesitancy in women with bladder neck obstruction, especially in those with small fiber neuropathy. Symptom flares are common, but did not reduce interest in repeated treatments, and scheduling injections before symptom recurrence may mitigate these flares.

To investigate the long-term effects of transurethral bladder neck incision (TUBNI) for female primary bladder neck obstruction (PBNO). We retrospectively reviewed seventy women diagnosed with bladder neck obstruction by video-urodynamic study (VUDS). TUBNI was performed for each patient, with incisions made at 2 different sites on the bladder neck. Postoperatively, patients were assessed by international prostate symptom score (IPSS), quality of life (QOL) and uroflowmetry. Follow-up data were available for 4-108 months (median 42 months) postoperatively. During follow-up, the IPSS, QOL, time to maximum uroflow rate, postvoid residual urine volume decreased significantly after TUBNI compared with preoperative [13.0 (10.0, 15.0) versus 3.0 (3.0, 8.0), P ＜ .001], [5.0 (5.0, 5.0) versus 2.0 (1.0, 3.0), P ＜ .001], [9.0 (5.0, 37.0) versus 6.1 (4.2, 8.7), P ＜ .001], [77.5 (23.5, 165.8) versus 0.0 (0.0, 30.0), P ＜ .001]. The maximum uroflow rate, average uroflow rate and the voided volume increased significantly compared with preoperative [7.0 (4.0, 10.3) versus 19.8 (12.8, 25.2), P ＜ .001], [3.0 (2.0, 5.0) versus 8.0 (4.9, 10.7), P ＜ .001] and [156.5 (85.0, 211.3) versus 261.3 (166.2, 345.6), P ＜ .001]. Several complications were identified after surgery, including bladder neck reobstruction, urethral stricture, and stress urinary incontinence, the corresponding number was 5 (7.1%), 7(10%) and 7(10%). Successful operation was achieved in 60/70 (85.7 %) patients. PBNO is a very rare yet easily treatable condition. VUDS is the primary diagnostic tool for the diagnosis of bladder neck obstruction in women, while TUBNI can effectively relieve obstruction symptoms and improve the quality of life for patients.

Transurethral incision of bladder neck in treatment of bladder neck obstruction in women

Objective To analyse and discuss the outcomes of female primary bladder neck obstruction(PBNO) with transurethral incision of the bladder neck(TUIBN). Methods From January 2004 to December 2013, 38 female patients who underwent transurethral incision of the bladder neck were retrospectively reviewed. The mean age of patients was 57.7 years and the duration of symptoms before diagnosis was 3.5 years. All patients presented with varying degree of difficulty of urination. There were 10 cases with lower abdominal discomfort and 20 cases with history of urinary infection. Preoperative examinations included physical examination, urine routine, international prostate symptom score (IPSS), quality of life (QOL), ultrasonography, urodynamics and cystoscopy. The urodynamic diagnostic criteria for PBNO were a maximum uroflow rate(Qmax) 20 cmH2O. All patients failed with 3-6 month alpha-blockers treatment and then underwent TUIBN. Results Follow-up data of all patients were available for 12-60 months (average 29.6) after operation. Successful recovery after operation was achieved in 33 of 38 (86.84 %). At the first year follow-up, the IPSS decreased from 26.63±3.15 to 13.00±7.18 (P<0.01), the Qmax increased from (8.65±1.32) ml/s to (15.91±3.89) ml/s (P<0.01), the postvoid residual decreased from (122.92±58.36) ml to (56.55±36.57) ml (P<0.01), and the Pdet.Qmax decreased from (52.18±7.31) cmH2O to (36.12±4.74) cmH2O (P<0.01), respectively. Of the 5 cases in which the first operation was not successful, 3 cases (7.89%) underwent an additional TUIBN 1 to 2 years after the initial operation and 2 cases detected bilateral renal hydronephrosis by B-ultrasound before operation underwent life-long catheter cystostomy. The second operation of 3 cases was successful. Pathological examinations revealed fibrous tissue hyperplasia with chronic inflammation in 32 cases, glandular cystitis in 4 cases and chronic inflammation with squmaors metaplasia in 2 cases. Conclusions The diagnosis of primary bladder neck obstruction in women is based on typical symptoms, urodynamics and cystoscopy. TUIBN is a safe and effective therapy for PBNO. Key words: Bladder neck obstruction; Transurethral; Voiding dysfunction

PRESSURE FLOW ANALYSIS MAY AID IN IDENTIFYING WOMEN WITH OUTFLOW OBSTRUCTION

Bladder outlet obstruction (BOO) in women has received less focus in the past, as compared with BOO in men; however, more recently, studies have further examined BOO and voiding dysfunction in women to define the various etiologies, diagnostic criteria, and treatment strategies. The differential diagnosis in women is broad and includes anatomic, neurologic, and functional etiologies. This review focuses on the functional etiologies, including dysfunctional voiding, Fowler's syndrome, and primary bladder neck obstruction in adult women.